Psychology Paperwork

Under the Workers Compensation system, allied health professionals need to show bench marking for patients progress through an Allied Health Treatment Request. You will be asked to complete this questionnaire at the beginning of your sessions, and after 8 sessions with your Psychologist.

Please allow 20 minutes to complete this questionnaire below in its entirety.

If you have any questions, please phone our rooms on (02) 4923 8999.

DASS21

DD slash MM slash YYYY

Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

Rating0123
MeaningDid not apply
to me at all
Applied to me to some degree,
or some of the time		Applied to me to a considerable degree,
or a good part of time		Applied to me very much,
or most of the time
I found it hard to wind down(Required)
I was aware of dryness of my mouth(Required)
I couldn't seem to experience any positive feeling at all(Required)
I experienced breathing difficulty (eg. excessively rapid breathing, breathlessness in the absence of physical exertion)(Required)
I found it difficult to work up the initiative to do things(Required)
I tended to over-react to situations(Required)
I experienced trembling (eg. in the hands)(Required)
I felt that I was using a lot of nervous energy(Required)
I was worried about situations in which I might panic and make a fool of myself(Required)
I felt that I had nothing to look forward to(Required)
I found myself getting agitated(Required)
I found it difficult to relax(Required)
I felt down-hearted and blue(Required)
I was intolerant of anything that kept me from getting on with what I was doing(Required)
I felt I was close to panic(Required)
I was unable to become enthusiastic about anything(Required)
I felt I wasn’t worth much as a person(Required)
I felt that I was rather touchy(Required)
I was aware of the action of my heart in the absence of physical exertion (eg. sense of heart rate increase, heart missing a beat)(Required)
I felt scared without any good reason(Required)
I felt that life was meaningless(Required)
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Tampa Scale for Kinesiophobia

Date of Birth(Required)
Rating1234
MeaningStrongly DisagreeDisagreeAgreeStrongly agree
1. I'm afraid that I might injury myself if I exercise(Required)
2. If I were to try to overcome it, my pain would increase(Required)
3. My body is telling me I have something dangerously wrong(Required)
4. My pain would probably be relieved if I were to exercise(Required)
5. People aren't taking my medical condition seriously enough(Required)
6. My accident has put my body at risk for the rest of my life(Required)
7. Pain always means I have injured my body(Required)
8. Just because something aggravates my pain does not mean it is dangerous(Required)
9. I'm afraid I might injure myself accidentally(Required)
10. Simply being careful that I do not make any unnecessary movements is the safest thing I can do to prevent my pain from worsening(Required)
11. I wouldn't have this much pain if there weren't something potentially dangerous going on in my body(Required)
12. Although my condition is painful, I would be better off if I were physically active(Required)
13. Pain lets me know when to stop exercising so that I don't injure myself(Required)
14. It's really not safe for a person with a condition like mine to be physically active(Required)
15. I can't do all the things normal people do because it's too easy for me to get injured(Required)
16. Even though something is causing me a lot of pain, I don't think it's actually dangerous(Required)
17. No one should have to exercise when he/ she is in pain(Required)
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DN4

DD slash MM slash YYYY

Instructions

To estimate the probability of neuropathic pain, please answer yes or no for each item of the following questions.

Does the pain have the following characteristics: Burning?(Required)
Does the pain have the following characteristics: Painful cold?(Required)
Does the pain have the following characteristics: Electric shock?(Required)
Is the pain associated with the following symptom in the same area: Tingling?(Required)
Is the pain associated with the following symptom in the same area: Pins and needles?(Required)
Is the pain associated with the following symptom in the same area: Numbness?(Required)
Is the pain associated with the following symptom in the same area: Itching?(Required)
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Roland-Morris Disability Questionnaire (RMDQ)

Full Name(Required)
DD slash MM slash YYYY
Tick the sentence if you are sure that it describes you today.